foundation of nursing questions and answers

Correct Answer: C

Rationale: The correct answer is C: Fundal height measurement of 18 cm. This finding suggests a hydatidiform mole because it is larger than expected for a 10-week pregnancy due to excessive trophoblastic proliferation. A: Blood pressure is within normal range. B: Nausea is common in early pregnancy and not specific to a mole. D: History of bright red spotting is more indicative of a miscarriage or other complications, not necessarily a mole.

Correct Answer: D

Rationale: The correct answer is D: Use electronic fetal surveillance to determine a baseline fetal heart rate. This is important in assessing the well-being of the fetus during labor, especially in the presence of genital herpes lesions. Monitoring the fetal heart rate helps in detecting any signs of distress or compromise due to maternal infection. A: Asking about the patient's last intake is important but not the immediate priority when managing a patient with active genital herpes lesions in labor. B: Taking a culture of the lesions might be helpful but not the immediate action needed in this situation. C: Asking about unprotected sex is relevant but not as critical as monitoring the fetal well-being during labor in this scenario. Overall, the most critical action is to monitor the fetal heart rate for any signs of distress related to the maternal herpes infection.

Correct Answer: D

Rationale: The correct answer is D: Hypogammaglobulinemia. This chronic health problem predisposes individuals to latex allergies due to reduced levels of immunoglobulins, increasing susceptibility to allergic reactions. Latex contains proteins that can trigger immune responses in individuals with compromised immune systems. Choice A: Herpes simplex is a viral infection and does not directly relate to latex allergies. Choice B: HIV weakens the immune system but is not specifically associated with latex allergies. Choice C: Spina bifida is a congenital condition affecting the spinal cord and does not directly impact the likelihood of latex allergies.

Correct Answer: B

Rationale: The correct answer is B: Constipation. When a patient is receiving opioids, constipation is a common side effect due to decreased gut motility. It is a priority assessment because untreated constipation can lead to serious complications such as bowel obstruction. Monitoring for constipation allows for early intervention with stool softeners or laxatives to prevent complications. Incorrect choices: A: Clostridium difficile - While important to consider in patients on antibiotics, it is not directly related to opioid use. C: Hemorrhoids - Although opioids can contribute to constipation which may exacerbate hemorrhoids, it is not the priority assessment. D: Diarrhea - Opioids typically cause constipation, so diarrhea is less likely to be a priority concern in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Stop taking aspirin. Aspirin is a blood thinner that can increase the risk of bleeding during and after surgery. By stopping aspirin before surgery, the woman's blood clotting ability will improve, reducing the risk of hemorrhage. A: Limiting intake of green leafy vegetables is not directly related to preventing hemorrhage in the postoperative period. B: Increasing water intake is important for overall health, but it does not specifically address the risk of hemorrhage related to aspirin use. D: Having nothing by mouth for 6 hours before surgery is important for preventing aspiration during anesthesia, but it does not directly address the risk of hemorrhage related to aspirin use.